Evidence-based medicine (EBM) endeavors to apply the best available evidence gained
from scientific methods to clinical decision making (1). It aims to assess the strength
of the evidence based on both the risks and benefits of treatments and diagnostic
tests. The quality of the evidence can be evaluated from the source type (mostly from
meta-analyses and systematic reviews of double-blind, placebo-controlled clinical
trials), as well as other factors which include statistical validity, efficacy, clinical
relevance, currency, and peer-review acceptance (2). A systematic review is, however,
the best method in order to identify, and critically evaluate all relevant research
on the effectiveness of a particular treatment. Initially, EBM was called, “a critical
appraisal,” as it described the application of basic rules of evidence. This evidence
was first presented by a group of clinical epidemiologists at McMaster University
in 1990, usage of this technique later expanded to all medical fields, and it has
now found global acceptance.
In our practice, it is generally accepted that interventional pain management techniques
have gained a definite place in the management of chronic pain syndromes. Actually,
the most important goal of pain medicine is to use a specific treatment; conservative
and/or interventional, for the right patient at the right time. Therefore, treatment
selection should be made according to the clinical diagnoses. In reality, patients
receive treatments that vary both due to their geographical location, as well as the
specialty of the treating physicians. According to the literature, the treatment of
pain syndromes should involve a multidisciplinary approach and should ideally entail
the evaluation and treatment of the patient by; physicians, physical therapists, and
psychologists well-versed in the complex biopsychosocial and pathophysiological causes
in the development and maintenance of pain syndromes. For the correct application
of interventional pain management techniques, both a good theoretical knowledge, as
well as practical experience is mandatory.
In evaluating the literature and developing recommendations, the Cochrane Database
and other recent systematic reviews are emphasized the most. Efficacy of a procedure
or drug is considered to have been demonstrated if the results of a randomized clinical
trial (RCT) are found to give statistically significant greater pain reduction, versus
a placebo for the primary outcome measure, and the results are then assessed by the
centers responsible for levels of EBM. All medications or procedures with efficacy
supported by at least one systematic review or positive placebo-controlled or procedure
or dose-response RCT, in which the reduction of chronic pain is a primary or co-primary
endpoint, are considered for inclusion. Published data, unpublished data (if available),
and the clinical experience of the authors are used to evaluate each of these modalities
in terms of their degree of efficacy, safety, tolerability, drug interactions, ease
of use, and impact on health-related quality of life. Nowadays, with such a plethora
of pain knowledge findings, the efficacy of pain management techniques have been described
in multiple randomized controlled trials, observational studies, retrospective studies,
and case reports. So, usually there is lots of existing information and data to support
any clinical practice.
Finally, evidence-based practice guidelines are written by the organizations responsible,
and these provide a good review of the literature in a context that makes it accessible
and useful to both the clinician and researcher (3, 4). Having looked at this issue
from different aspects, one comes to understand that in the new and modern world of
pain practice, EBM, systematic reviews, and guidelines are a major part of interventional
pain management. A well designed management strategy starts with an accurate evaluation
process to identify the pain diagnosis. It is of the utmost importance that so-called
red flags are checked first, as they may be indicative of an underlying primary pathology,
which needs adequate attention and treatment prior to the application of symptomatic
pain management techniques. With interventional pain management techniques, a non-algorithmic
approach to patients can be problematic or overly expensive, so interventionist should
always remain cautious.
Consequently, evidence based practice guidelines are of greater practical value when
they are specific for each different pain diagnosis. It is recommended that the interventionist
takes note of the algorithmic pattern and follows the rules, meanwhile observing the
patient for potential red flags.
The series of articles published in the EBM section of pain practice and pain physician
journals have covered the most important pain diagnoses and using these guidelines
is strongly recommended to all pain physicians. These guidelines could help to solve
the above mentioned impediments. These articles have been published between 2009 up
to the present time. Different pain syndromes such as; trigeminal neuralgia, cervical
and lumbar radicular pain, facetogenic pain, headaches, phantom pain, and post herpetic
neuralgia, have been described in these articles and an algorithmic treatment approach
has been planned for them. Essentially, this series of articles forms global guidelines
for interventional pain management.
Due to the continual development of more specific diagnostic tools and to the improved
understanding of pathophysiology, and consequently the mechanism of action of the
different pain treatment options, it is generally accepted that treatment selection
for chronic pain syndromes will become based more on the mechanism. Careful attention
to this evolution is warranted and, when necessary, updates to the guidelines should
be made. More and more guidelines are being released according to the recent literature
and if necessary these are corrected by the latest findings (5, 6). Based on the philosophy
that guideline panels should make recommendations on whether to administer, or not
administer, a particular intervention, the taskforce chose to classify recommendations
into strong and weak levels. The relationship between the quality of evidence and
strength of the recommendation are complex issues, which requires the careful consideration
of numerous factors. For this purpose multiple meetings and panels have been facilitated
by pain organizations to gather different opinions in order to design or revise a
guideline (6, 7).
The modern pain physician realizes that scientific and relevant evidence is essential
in clinic care, policy-making, dispute resolution, and law. Thus, evidence-based pain
practice provides strong, acceptable, trustworthy information by; systematically acquiring,
analyzing and transferring research findings into clinical, management, and policy
arenas (7-9). It is hoped that in the near future more attention will be payed to
these aspects of pain practice by pain physicians and that further useful guidelines
for each parts of this field are created, so a treatment can only be recommended when
the effects of it, have been proven in well-designed trials and analyzed by centers
with appropriate expertise.